INTERROGATING THE SKILLED NURSING STAYS OF HOMELESS AND SERIOUSLY ILL OLDER ADULTS

Abstract The culture change movement has fostered an intentional move away from restrictive ethos of care in hospitals, post-acute rehabilitation, and skilled nursing. However, for the millions in the United States who are uninsured, Medicaid-insured, or dual-eligible are less likely to access ‘deinstitutionalized’ healthcare environments. This presentation presents findings from a constructivist grounded theory study, Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP), on the role of skilled nursing in the experiences of palliative care patients with histories of homelessness. Through provider interviews (n=30), field observations (n=12), and longitudinal chart documentation of a subset of homeless palliative care patients with stays in skilled nursing (n=13), this presentation will reflect on major findings: (1) barriers to skilled nursing entry; (2) successes and challenges in transitioning into skilled nursing residence; (3) acts of resistance to (re)institutionalization; and (4) discharge options and outcomes. Results showcase a need to fill the residential service gap between supportive housing and skilled nursing care and policy change that incentivizes consumer-directed practices for all.

community responses are emerging.Focusing on the 10 U.S. cities with the largest adult homeless populations, this exploratory study had two objectives: 1) through a web-based search of the "grey literature," the identification of organizations developing or adapting programs to serve the palliative care needs of homeless adults; and 2) through in-depth zoom interviews with directors, gaining an understanding of the programs' core aspects as well as their successes and challenges in development, implementation, and sustainability.The 18 interviewed agencies fell into two distinct service categories, healthcare/palliative organizations and homelessness/housing organizations.Identified modifications included targeted advanced care planning (ACP) groups, the development of an ACP repository for unhoused persons, rapid re-housing for terminally ill patients, harm reduction strategies, and hospice options in shelters.Common themes were the challenges of working across multiple systems and the lack of dedicated resources and funding for initiatives to support the population's multiple and complex needs.The discussion highlights the need for greater organizational resources and flexibility in both the healthcare and homeless systems to promote value-based-goal concordant care for homeless adults.Palliative and end-of-life (PEOL) care offer many benefits to those with life-limiting illness; however, older unhoused individuals face barriers in accessing these types of care.The purpose of this study was to explore healthcare and social service providers' perspectives on approaches and challenges to addressing PEOL needs among unhoused individuals in Colorado.A descriptive, convergent mixedmethods design was used, including an online survey and semi-structured interviews.Participants were eligible if they worked in healthcare or social services in Colorado and provided direct care/services to adults.Guided by the Behavioral Model for Vulnerable Populations, the survey assessed satisfaction with care provided and identification of challenges in providing care along predisposing, enabling, and need contexts.Interviews focused on deeper accounts of provider experiences.Thematic analysis was used to evaluate qualitative data.Sixty-seven providers completed the survey, and 17 participated in interviews.Only 30% were satisfied with care provided to unhoused individuals with life-limiting illness within their organization.Lack of informal care support, mental illness, substance use, complex care needs, and lack of community resources were most frequently identified in the survey as challenges in providing care.Interviews highlighted person-centered and holistic approaches to care, as well as challenges of providing complex care in the context of an inhumane lack of resources.Tailored PEOL interventions, including street-based palliative care and social model hospice homes, were discussed as possible solutions.This study highlights humanizing approaches within structural challenges to providing PEOL care for unhoused individuals, and highlights potential opportunities to improve access to care.Despite well-known inequities in rates of serious illness and premature mortality among people experiencing homelessness, as well as the unique biopsychosocial and spiritual care needs of people with homelessness histories, there is a lack of translational research focused on palliative care service delivery within permanent supportive housing.This presentation will present data from the Research, Action, & Supportive Care at Later-life for Unhoused People (RASCAL-UP study) to describe the current practices, perceived barriers, and recommendations in providing support to older permanent supportive housing residents during serious illness and end-of-life.Through a thematic analysis of interviews with direct care providers (n=30) across multiple care settings, themes were identified: 1) the importance of on-site relationships; 2) cross-sector collaboration barriers; 3) interdisciplinary communication barriers within permanent supportive housing teams; 4) environmental and spatial considerations; and 5) missing levels of care between supportive housing and higher levels of medical care.From these results, we put forth recommendations for translational research, supportive housing policy, and capacity-building efforts for interdisciplinary and cross-sector healthcare and housing teams.The culture change movement has fostered an intentional move away from restrictive ethos of care in hospitals, post-acute rehabilitation, and skilled nursing.However, for the millions in the United States who are uninsured, Medicaid-insured, or dual-eligible are less likely to access 'deinstitutionalized' healthcare environments.This presentation presents findings from a constructivist grounded theory study, Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP), on the role of skilled nursing in the experiences of palliative care patients with histories of homelessness.Through provider interviews (n=30), field observations (n=12), and longitudinal chart documentation of a subset of homeless palliative care patients with stays in skilled nursing (n=13), this presentation will reflect on major findings: (1) barriers to skilled nursing entry; (2) successes and challenges in transitioning into skilled nursing residence; (3) acts of resistance to (re)institutionalization; and (4) discharge options and outcomes.Results showcase a need to fill the residential service gap between supportive housing and skilled nursing care and policy change that incentivizes consumer-directed practices for all.

USING PHOTOVOICE TO UNDERSTAND SOCIAL MODEL HOSPICE FROM RESIDENTS' PERSPECTIVES Francine Jensen, Utah Valley University, Orem, Utah, United States
Individuals who experience homelessness and are diagnosed with six months or less to live are disadvantaged at a critical time of life.Many people choose to die at home using hospice services supported by family or close friends, but those without stable housing are unable to access hospice, demonstrating inequitable access at the end of life.For some, social model hospice (SMH) care is being provided free of charge by communities to increase access to hospice services for these individuals.The literature about SMH is growing, but currently missing are the voices of those receiving this care and its impacts on their end-of-life experiences.Using photovoice, a community-based participatory method, three residents shared their first-person perspectives using disposable cameras to document meaningful aspects of care, both positive and negative, and helped researchers analyze themes.Until this study, photovoice had not been used with people experiencing homelessness at the end of life.We found participants eager to take part in all aspects of photovoice as their health permitted.Their perspectives documented and informed the humanistic side of SMH care, illuminating the value of respect, care, autonomy, meeting physical needs, and forming supportive relationships; few criticisms were offered.Consistent with photovoice aims, this method is a powerful research tool involving a disadvantaged group who provided visual commentary on what is working and what could improve at one SMH location.Findings can inform policy decisions for communities interested in starting SMHs and help functioning SMHs make programmatic decisions to support vulnerable residents.

THE ESSENTIAL ROLE OF PAID CAREGIVERS IN HOME-BASED DEMENTIA CARE
Chair: Jennifer Reckrey Discussant: Joanne Spetz Paid caregivers (e.g., home health aides, other home care workers) provide essential support to the rapidly growing number of people with dementia living in the community.This symposium presents innovative findings on the role of paid caregivers in home-based dementia care though exploration of the clinical, family, and care-delivery contexts in which paid caregivers work.First, Reckrey et al describe the scope of paid caregiving in dementia using nationally representative data examining factors associated with receipt of paid care among older adults with overlapping dementia and non-dementia serious illness.Next, we examine mechanisms of delivering paid care: Osakwe et al explore paid caregiver perceptions about the use of telehealth in home health and identify paid caregivers concerns about routine use of this technology in care of people with dementia, and Gordon-Wexler et al explore family caregiver perspectives on navigating Medicare and Medicaid insurance for people with advanced dementia and the challenges they experience coordinating paid care.Finally, we explore how paid caregivers work with other care team members.Quach et al discuss multidisciplinary perspectives about how paid caregivers support person-centered and relationship-centered care to family dementia caregivers, while Fabius et al examine information sharing practices within home care agencies and describe differences and similarities in information sharing needs for people with and without dementia.Taken together, these presentations highlight the important ways that paid caregivers work with providers and families within the care delivery system and identify ways to better support and integrate these essential workers into dementia care teams.This is a Paid Caregiving Interest Group Sponsored Symposium.Little is known about receipt of paid care for individuals living at home with dementia and other non-dementia serious illnesses.This retrospective cohort study sought to characterize receipt of paid care among individuals with impairment in self-care activities and/or other manifestations of serious illness in the context of family caregiving and socioeconomic status.Data from participants ≥65 years enrolled in the Health and Retirement Study between 1998-2018 with new-onset need for help in ≥1 self-care task was linked to fee-for-service Medicare claims (sample n=2,521).We found that those who received paid care experienced higher healthcare utilization than those without paid care.Receipt of paid care was highest among those with multiple manifestations of serious illness: 41.7% of those with selfcare impairment, dementia, and non-dementia serious illness received ≥40 hours of paid care per week.When present, paid care accounted for 54% of total caregiving hours.In multivariable models, those with Medicaid were more likely to receive paid care (p<0.001),but those in the highest income quartile received more hours of paid care (p=0.05.)Those with non-dementia serious illness were more likely to receive paid care (p<0.001),but those with dementia received more hours of paid care (p<0.001).The role of paid caregivers grows as people experience multiple manifestations of serious illness and high care hours are common among those with dementia.Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill living at home.
Abstract citation ID: igad104.1194INTERROGATINGTHE SKILLED NURSING STAYS OF HOMELESS AND SERIOUSLY ILL OLDER ADULTSNamrata Mukherjee 1 , Ian Johnson 2 , and Michael Light 3 , 1. University of Tennessee, Knoxville, Knoxville, Tennessee, United States, 2. University of Tennessee, Knoxville, Tennessee, United States, 3. University of Washington Palliative Care Training Center, Seattle, Washington, United States

AN INHUMANE LACK OF RESOURCES": PERSPECTIVES ON PALLIATIVE AND HOSPICE CARE FOR UNHOUSED OLDER ADULTS
M. Pilar Ingle 1 , Asia Cutforth 1 , and Elise Matatall 2 , 1. University of Denver, Denver, Colorado, United States, 2. Elevated Denver, Denver, Colorado, United States

OPPORTUNITIES AND BARRIERS IN INTEGRATING PALLIATIVE CARE SERVICES INTO PERMANENT SUPPORTIVE HOUSING Ian
Johnson 1 , Anthony Traver 2 , and Michael Light 3 , 1. University of Texas-San Antonio, San Antonio, Texas, United States, 2. The Ohio State University, Columbus, Ohio, United States, 3. University of Washington Palliative Care Training Center, Seattle, Washington, United States